This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

A limited number of studies have assessed the pathways to care of patients experiencing
psychosis for the first time. Helpline/clinic programs may offer patients who are
still functional but have potential for crisis an alternative that is free from judgment.

Methods

In this study we report on patient calling a round-the-clock crisis helpline for suicide
prevention supported by psychiatric facilities in Mumbai, India. Chi-square and test
of mean differences were used to compare outcomes between first-episode patients and
those with a previous history.

Results

Within five years, the helpline received 15,169 calls. Of those callers, 2341 (15.4%)
experienced suicidal ideation. Two hundred and thirty four patients opting for counseling
lasting 12 months agreed to a psychiatric assessment. Of those, 32 were fist time
psychosis sufferers, whereas, 54 had previously been psychotic. Of all psychiatric
assessments, the clinic received 94 patients with ‘first-episode psychosis’. We found
that the duration of illness was significantly shorter (17 vs. 28 months) and suicide
attempts were fewer (16 vs. 21) in first-time psychosis sufferers compared to those
with a treatment history.

Conclusions

We conclude that some first-episode patients of schizophrenia and other disorders
do access services by using helplines. We also argue that helplines may be somewhat
immune to stigma, allowing patients a safe alternative when finding help.

Keywords:

Introduction

There is little doubt that patients experiencing psychosis benefit greatly from early
intervention. Consequently, the mental health community has concentrated on bringing
mental health services to patients as quickly as possible. In order to facilitate
contact with mental health professionals (MHP), mental health centers are implementing
early intervention programs with innovative strategies such as helpline services and
clinic access. It is curious; however, that most studies investigating mental health
care access have focused on hospital-based psychiatric interventions while little
attention has been spent investigating the use of helpline programs. This is perhaps
not surprising as traditionally, individuals presenting with psychosis are likely
to be taken to the hospital for treatment in favor of other facilities. Secondly,
there is still great stigma associated with mental health problems, leading individuals
and family members to avoid seeking treatment until absolutely necessary [1]. Individuals presenting with psychosis are especially afraid of being diagnosed as
schizophrenic, not realizing that there are a number of causes for psychosis. Patients,
then, if not opting for a hospital may go to clinics not advertising mental health
services, perhaps to hide their primary reason for seeking help.

Duration of untreated psychosis (DUP) is an important prognostic variable [2,3]. Early detection programs are required to decrease the period between illness onset,
diagnosis and treatment in first-episode psychotic patients. Long duration of illness
is associated with poor outcome in schizophrenia [4]. It is reasonable then that early treatment should prevent psychosis or limit the
damage caused by psychosis which is supported by neurobiological, and phenomenological
data [5]. Studies have also shown that determinants of DUP that facilitate early treatment
are education, awareness, and research to name a few. It is imperative that any strategy
implemented for early intervention be culturally sensitive and pragmatic. What works
in North American and European countries may not necessarily work in India due to
cultural perceptions of mental illness [6]. Consequently, people of different cultures may choose to seek help at later or earlier
stages of an illness or may choose alternatives not considered by others.

A study by Bechard-Evans et al. [7] showed that longer DUP (help seeking component) was significantly associated with
earlier age of onset, diagnosis of schizophrenia spectrum psychosis, and poor pre-morbid
adjustment during adolescence. Longer DUP (referral component) was associated with
earlier age of onset and first help-seeking contact having been made with a non-medical
professional [7]. Although there is agreement with respect to an association between delay in treatment
of psychosis and outcome, little is known regarding how patients suffering from a
first psychotic episode find help. The process of finding help is complex and involves
a diverse range of contacts. It is also likely to influence treatment delay [8]. This was explored in the present research.

A limited number of studies have assessed the pathways to care of patients experiencing
psychosis for the first time. A recent study by Cougnard et al. [9] examined how patients of psychosis obtained care from the onset to being admitted.
Twelve percent of subjects were first admitted without any previous-contact with a
helping individual (MHP, general practitioners, others…). For approximately 70% of
patients, the first helping contact was a health care professional. Thus, delay in
access to care does not appear to result primarily from inadequate management by health
care professionals, suggesting there may be reluctance from patients to seek help
in the first place. Clearly, tools that allow for easy, stigma-free contact with MHP
should enhance early intervention efforts [9].

As previously mentioned, hospital-based mental health facilities receive mental health
patients who are already in crisis. Helpline/clinic programs may offer patients who
are still functional but have potential for crisis an alternative that is free from
judgment, allows for the complete description of symptoms, provides an active listener,
and is free from financial cost. A person experiencing distress in all aspects of
their lives can rely on such a service for suggestions relating to treatment or to
facilitate a visit to a mental health professional. These aspects of helplines to
our knowledge have not been sufficiently assessed.

In this study we report on a community-based clinic with a crisis helpline aimed at
the prevention of suicide from the metropolitan city of Mumbai. We describe some demographics
behind helpline use, focusing on psychotic and first-time psychotic sufferers calling
the helpline. Of special interest was the prevalence of patients seeking help following
the call.

Method

A helpline was implemented for crisis and suicide intervention for the entire city
of Mumbai. This was the first helpline in Mumbai for the prevention of suicide and
for mental health crises in general which was publicly advertised by the media and
in press conferences. It was based in a residential location in the community. This
helpline was available 24 hour per day and seven day per week with trained mental
health professionals receiving all calls. It is important to note that those manning
the telephones were not volunteers. Specifically, they were trained psychologists,
social workers, and therapist counselors. Callers were provided with two options when
they called. They were given the option of “counseling” or “psychiatric assessment.”
Within the facility, psychiatric assessment was available, and patients were not obligated
to visit a hospital. Some patients came to the centre and opted for counseling, some
stayed with counselors for therapy, and others agreed to psychiatric assessments.
Those who stayed with counselors for one year were also assessed by psychiatrists.
Duration of illness and the general history of the patient were determined from questions
to the patient and family and by the professional opinion of the psychiatrist.

Data collection and statistics

All data were collected by mental health professionals at the time of the call and
any following assessment. The database was compiled from the records and frequencies
and tests of means analyzed using SAS (Statistical Analysis System inc, version 9.1,
NC, USA, 2009). All data are reported as frequency, percentage, and means. When appropriate
odds ratios (OR) with confidence intervals were calculated by standard formulations.
Tests of association between nominal variables were conducted using the Chi-Square
test. Means were compared using the independent samples t-test. All tests were considered significant when the Type 1 error was less than 5%
(p < .05). Formal ethics were not required as this is an evaluation of a service. Consequently,
patient permission is not required to publish this data.

Results

Over a five year span, the helpline received 15,169 calls. Of those callers, 2,341
(15.4%) experienced suicidal ideation. These callers visited the outpatient clinic
for assessment and subsequent psychosocial intervention. From the callers that experienced
suicidal ideation, 781 (34%) were assessed by psychiatrists (Table 1), whereas, 1560 (66%) received psychosocial assessment and intervention. Of those
receiving psychosocial assessment and intervention, 234 (15%) remained in therapy
and at the end of 12 months consented to psychiatric assessment (Table 2). Of the 234 patients who remained in counseling 94 (40%) were observe to have early
psychosis. Thirty two (17.7%) of the 94 patients were seen by a psychiatrist following
12 months of counseling, whereas 62 (30.5%) were seen by a psychiatrist shortly after
the call to the hotline (Table 3). Of the 94 psychosis sufferers, 54 (57.4%) were previous-contact patients, with
22 (40.7%) of the 54 having a non-affective psychosis (Table 2).

Table 2. Frequency and percentage for diagnoses treatment history for those patients assessed
by a psychiatrist after 12 months of counseling

Table 3. Frequency distribution and percent of first-contact and previous-contact patients
categorized by direct assessment (Gr1) or assessment following 12 months of counseling
(Gr2) by diagnosis

Overall, 15% of patients using the helpline accessed the care from a mental health
professional or psychiatrist. Of these patients, 1015 (43.3%) could be fully assessed
for diagnosis. Thus, 94 (9.2%) were never treated, whereas, 144 (14.1%) were previous-contact
patients of early phase psychosis. Of the 1015 patients with suicidal ideation assessed
in the community clinic, 383 (37.7%) were first-contact patients. Of the group diagnosed
with non-affective psychosis, 94 (39.5%) patients were first-contact (early psychosis)
and 144 (60.5%) had a history of treatment for schizophrenia (Table 3). The duration of illness in the first-contact psychosis group was significantly
lower (17 months) in comparison to patients with previous psychiatric contact (53 months),
t (236) = 48.247, p < .001. In the first-contact group, 16 (17%) had a history of suicide attempts compared
to 21 (14.5%) in the previous psychiatric contact patients. This association was not
significant, χ2(1) = 0.257, p = n.s.

A range of psychiatric diagnoses were seen in the first-contact group that had never
been treated, such as major mood disorders (MMD), anxiety-depression, substance use
disordered (SUD), and personality disorders (PD). Fifty-six (14.6%) patients in the
group that had never been treated did not qualify for any axis 1 or axis II DSM IV
diagnosis (Table 3).

In group 1 (psychiatric assessment, Table 1), the results indicate that patients with bipolar disorder were represented equally
among patients with a history of psychiatric treatment and first-contact patients.
SUD patients had a greater representation in the treatment history group compared
to the first-contact group (OR = 2.288, p < .05). For all other diagnoses, there was a greater representation in the first-contact
patients (OR range = 0.517 to 2.289, p’s range < .05 to < .01; see Table 1). In group II (psychosocial assessment and intervention group, Table 2) the results suggest that there were no differences in representation between first-contact
and previous-contact patients in diagnoses of MMD, SUD, anxiety-depression, bipolar
disorder, PD (Table 2). For nonaffective psychosis there was a greater representation in the treatment
history group, OR = 3.18, p < .01, whereas, there was a greater representation of no diagnosis for the first-contact
group (Table 2).

Finally, when comparing first-contact and previous-contact patients in the two assessment
groups, the results show that for patients with all diagnoses, those who received
direct psychiatric assessment and those who received psychiatric assessment from group
counseling differed significantly in whether they were first-contact patients or were
patients who had previously been in contact with mental health professionals. First-contact
patients of all diagnoses were less likely to receive direct psychiatric assessment
than patients with previous-contact. On the other hand, first-contact patients with
all diagnoses were more likely to receive psychiatric assessment from group counseling
than patients who had previous-contact (χ2 range = 11.4 to 65.9, p’s range = <.01 to < .05; see Table 3).

Discussion

Helpline services are a welcome addition to an ever growing toolset for tending to
mental health issues. It is especially important to offer an opportunity for early
contact, identification, and treatment for mental disorders as well as to those with
psychosocial problems. When the crisis callers attend an outpatient clinic the advantages
increase in terms of accessibility for individuals with previously untreated illnesses,
particularly early psychoses.

Access to care

Several strategies have been adopted to reach out to patients who are in the early
phase of illness with education being the best [10]. General practitioners, public education, and school programs have made use of the
internet, printed promotional material, lectures, and seminars. Workshops have also
been used by early intervention programs in order to reduce stigma and raise confidence
that using the programs will be beneficial.

In Indian culture, particularly in Mumbai where this study was conducted, there is
an open-door system. A patient does not need to be referred by an agency to attend
a walk-in centre. Patients in this culture have a range of choices available for obtaining
help and treatment. They approach faith healers, religious leaders, physicians of
alternative medicine, family physicians, psychiatrists, counselors, psychiatric social
workers, volunteers of social groups, voluntary agencies, and various support groups.
A crisis helpline is only one of many options available to patients and families for
obtaining information, opportunities for discussion, interventions, and even referrals.

In spite of an open door policy, families generally seek professional help only when
symptom severity escalates to the point where there is danger to the patient or care-givers.
This reluctance to seek help is likely due to stigma; the fear of being labeled with
a mental illness results in a resistance to seek treatment. A limited number of studies
have assessed the pathways to care of patients experiencing psychosis for the first
time. In the present study, patients received access to care using a helpline. Sixty
six percent of patients decided to see a mental health professionals, whereas, only
33% chose to see a psychiatrist. Furthermore, of all patients who were first-contact
psychotics (94), 32 (17%) of patients were assessed immediately by a psychiatrist,
whereas, 62 (30.5%) were assessed after 12 months of counseling. It is clear that
in the early phase of illness patients and relatives prefer to see a mental health
professional other than a psychiatrist. This trend may be related to stigma as a patient
may defer being diagnosed for as long as possible with the hope that counseling will
be sufficient. We found that a professional is most likely to be contacted by telephone
when the situation is urgent. A similar trend is observed for patients with past and
ongoing treatment history. This study suggests that early phase patients prefer to
contact non-psychiatric mental health professions. Crisis helplines also provide ready
access to early psychosis patients who have never been treated; this can help prevent
a delay in treatment. Health service development efforts in early intervention need
to consider establishing non-hospital based community services integrated with help
lines to expand the network for early identification.

In our study we observed that diagnoses were not equally distributed among patients
with or without treatment history. First-contact patients were more likely to be in
psychosis, be MMD, or anxious-depressed, but less likely to be SUD, or PD compared
to patients with a treatment history. In patients that received counseling for 12 months
the pattern was somewhat different. First-contact patients were less likely to be
psychotic but more likely to be without diagnosis then those patients with a treatment
history. This suggests that first-contact patients are more likely to be in crisis
and have chosen to access the helpline. Perhaps the anonymity conferred by the helpline
is conducive to seeking help and obtaining advice from a MHP from which a reasonable
course of action can be taken that is free from judgment.

When considering patients who where directly assessed after calling the helpline and
those assessed after 12 months of counseling, it was evident that there were relatively
more patients diagnosed in the counseling group compared to the direct assessment
group. This was true for all categories. Patients that required counseling for 12 months
were possibly more troubled than those agreeing to an immediate assessment. We have
no data to suggest a mechanism. However, there may have been social/cultural reasons
preventing an immediate diagnosis. Stigma, as mentioned, may indeed be the major reason
for this phenomenon.

DUP is an important prognostic variable [2,3]. It is known that long illness duration is associated with poor outcome in schizophrenia.
In our study we show that duration of illness is significantly shorter in the ‘first-contact’
group (17 months) compared to patients with a history of psychosis (26 months). It
is possible then that helpline services can get patients help early in the illness
process, preventing treatment delays. A caveat, however, is whether or not a first-contact
person on subsequent calls will have an increase in DUP compared to their first-contact.
Nevertheless, there are psychosocial and cultural factors influencing DUP and consequently
on the treatment which is reported from low- and middle-income countries [11-14].

Although there is agreement on the association between delay in treatment of psychosis
and outcome, less is known regarding how patients suffering a psychotic episode for
the first time find help. In the present study we found that for both first-episode
(n = 94) and previous-contact patients (n = 144) who had equal access to care, mean
durations of illness were 17 and 53 months respectively. It is clear that the availability
of crisis helplines can effectively reduce treatment delay and provide early and easy
access for diagnosis and treatment. Some studies have argued that family members’
levels of knowledge of schizophrenia may not necessarily have a major impact upon
the length of treatment delays. Early psychotic symptoms are often attributed to depression,
lack of motivation or relational stressors. Family members’ decisions to seek help
often were solidified only after the emergence of unbearable psychotic symptoms or
socially disruptive behaviors. This is one explanation of why they are more likely
to contact during times of crisis [15,16].

Individuals with a first-episode of psychotic illness are known to be at a high risk
of suicide, yet little is understood about the timing of risk in this critical period
of illness [12,13]. Another interesting finding is the rate of suicide attempts prior to contacting
the hotline. Seventeen percent of never treated patients and 14.5% of patients with
previous treatment had a history of suicide. The fact that the suicide rate is high
amongst first-episode patients before contacting services is well known [17]. Contact through our crisis helpline demonstrated in this study offers an excellent
opportunity for prevention by intervening early during illness. It has been consistently
demonstrated that suicide attempts can be reduced during the first episode by treating
them in early intervention programs. Helplines and community-located clinics can facilitate
this initiative and should be encouraged.

Conclusions

In this study we reported on a community-based clinic with a crisis helpline for the
prevention of suicide from the metropolitan city of Mumbai. This clinic was not promoted
for detection and treatment of early psychosis. However, in spite of this fact, we
did make contact with a number of patients with psychotic disorder for whom we were
able to help. We concluded that some first-episode patients of schizophrenia and other
disorders do access the services by using helplines. However, more research is required
to determine whether community-based round-the-clock helplines can be a supportive
service to traditional-based services. The present study highlights four main points
which can be useful in early intervention initiatives: 1. It is not necessary to popularize
the term ‘psychosis’ to get the patients into treatment; 2. Centers based in the community
where people live offer more comforting access to care; 3. People do recognize mental
health issues and approach the easily available services; 4. Barriers in access to
care in contrary to the very philosophy of ‘early intervention.’ If the concept has
to be translated in reality, patients need to be seen whenever they need and wherever
they live.

Abbreviations

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

AS conceptualized, designed, supervised and did psychiatric assessment for the study
as principal investigator; MJ, was involved in interpretation of data and writing
the manuscript; LS performed the statistical analysis; MT, GS, and SI did patient
assessment, data management, and managed the helpline; NS supervised data management
and psychiatric assessment; and YB undertook the responsibility of writing and finalizing
the draft for submission. All authors read and approved the final manuscript.